I tried to attach this but it would not let me, you can find this on the ACR website as well.
Guidelines per the American College of Radiology.
II. DIAGNOSTIC IMAGING REPORTS
An official interpretation (final report) must be generated and archived following any examination, procedure, or officially requested consultation regardless of the site of performance (hospital, imaging center, physician office, mobile unit, etc.).
A. Components of the Report
The following is a suggested format for reporting:
1. Demographics
a. The facility or location where the study was performed.
b. Name of patient and another identifier.
c. Name(s) of referring physician(s) or other health care provider(s). If the patient is self referred (a patient who seeks medical care without a physician referral), that should be stated.
d. Name or type of examination.
e. Date of the examination.
f. Time of the examination, if relevant (e.g., for patients who are likely to have more than one of a given examination per day).
g. Inclusion of the following additional items is encouraged:
i. Date of dictation.
ii. Date and time of transcription.
iii. Patient's date of birth or age.
iv. Patient's gender.
2. Relevant clinical information
3. Body of the report
a. Procedures and materials
The report should include a description of the studies and/or procedures performed and any contrast media and/or radio-pharmaceuticals (including specific administered activities, concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Any known significant patient reaction or complication should be recorded.
b. Findings
The report should use appropriate anatomic, pathologic, and radiologic terminology to describe the findings.
c. Potential limitations
The report should, when appropriate, identify factors that may compromise the sensitivity and specificity of the examination.
d. Clinical issues
The report should address or answer any specific clinical questions. If there are factors that prevent answering of the clinical question, this should be stated explicitly.
e. Comparison studies and reports
Comparison with relevant examinations and reports should be part of the radiologic consultation and report when appropriate and available.
4. Impression (conclusion or diagnosis)
a. Unless the report is brief, each report should contain an “impression” section.
b. A specific diagnosis should be given when possible.
c. A differential diagnosis should be rendered when appropriate.
d. Follow-up or additional diagnostic studies to clarify or confirm the impression should be suggested when appropriate.
e. Any significant patient reaction should be reported.
5. Standardized computer-generated template reports
Standardized computer-generated template reports should be designed to satisfy the above criteria.
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/comm_diag_rad.aspx